Provider Demographics
NPI:1811085202
Name:GRUBER, THOMAS JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:GRUBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 ARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2027
Mailing Address - Country:US
Mailing Address - Phone:815-262-3001
Mailing Address - Fax:815-229-2508
Practice Address - Street 1:1603 ARDEN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2027
Practice Address - Country:US
Practice Address - Phone:815-262-3001
Practice Address - Fax:815-229-2508
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41045207L00000X
MO2003027199207L00000X
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E18413Medicare UPIN